Yesterday, the Centers for Medicare and Medicaid Services released their report on U.S. healthcare expenditures in 2014. Cost curve up.

Stars and Stripes reports on a Congressional hearing about TRICARE which provides health benefits to military family members and retirees. The report caught the FEHBlog’s eye because a blue ribbon panel had recommended replacing TRICARE with a program similar to the FEHBP.  The article indicates that Congress is more likely to seek to fix and not scrap TRICARE. Attention appears to be focusing on “a blended system that would direct more [TRICARE] beneficiaries to base hospitals, rely more on clinics in places with smaller military populations, and offer guard and reserve troops insurance plans like ones offered to federal workers.

Healthcare Data Management reports on findings stemming from a mock cyberattack involving twelve insurers conducted this past summer.

Identification and response gaps by the health plans during the attacks were revealing. Some of the plans, Gelinne said, did not even know who had authority to order taking down the claims processing system during the attack. That’s one reason it is important to establish formal integrated cyber response plans across the organization, he added. “It truly is a team sport.”
Other findings included: 

* As the attack unfolded, HITRUST shared intelligence with the plans, but participants—who were to share information such as threat indicators among themselves and with HITRUST—were reluctant to do so. That aligns with a recent HITRUST survey that found 85 percent of organizations use their own threat indicators but only five percent share the data.

* Participants were uncertain about how to quantify losses and submit insurance claims, and what to expect after reporting an attack. “Each insurer is likely to have distinct processes,” according to information from HITRUST. “Incident response plans should include information on how to engage insurers.”

* Only two of the 12 health plans referenced their organization’s incident response plan while responding to the attack. “While the pace of a live situation may make strict adherence to documented plans impractical, having ready access to key information and adhering to roles and responsibilities defined in the plan can improve efficiency,” according to HITRUST.

* Organizations need to bring in law enforcement at the appropriate time; several health plans engaged police before evidence of a crime had been established. “Law enforcement can aid in compiling and preserving evidence, but acting too soon may distract efforts from aspects of the investigation and recovery process,” HITRUST cautioned.

A valuable drill.

Today the OPM Director  Beth Cobert commented in her blog on the progress that OPM is making in notifying people affected by the agency’s data breach.  She also announced that OPM has created

a verification center [website] to help individuals who have had their information stolen in the malicious cyber intrusion carried out against the Federal Government. This verification center will help those who believe their data may have been taken but have not received a notification letter from the government. The center will also assist individuals who have received a letter letting them know they were impacted by the background investigation records intrusion, but who have lost the PIN code that allows them to sign up for the free services that the Federal Government is providing.

The Wall Street Journal reported today on why the U.S. pays higher prices for prescription drugs than other industrialized countries.  The short answer is that other industrialized countries rely on government price controls.

The pharmaceutical industry says controls such as those seen in Europe discourage investment in research and deny patients access to some drugs. “The U.S. has a competitive biopharmaceutical marketplace that works to control costs while encouraging the development of new treatments and cures,” said Lori Reilly, an executive at the Pharmaceutical Research and Manufacturers of America, a trade association. If U.S. pricing fell to European levels, the industry would almost certainly cut its R&D spending, said Mr. Evans, the health-care analyst. “Does the U.S. subsidize global research? Absolutely, yes,” he said. 

Surely there must be a happy medium.

On the bright side, the Journal also reported on successful, entreprenurial initiatives by health care providers to better educate patients about their health care conditions and hospital discharge plans.

Research shows patients don’t absorb much of the medical information they receive from their physician and are often wrong about what they do remember. Patients “immediately” forget 40% to 80% of what the doctor told them, according to a 2003 paper in Britain’s Journal of the Royal Society of Medicine.
Some 50% of patients discharged from hospitals make mistakes in their aftercare with medications, and many end up back in the hospital, says Brian Jack, chief of family medicine at Boston Medical Center, who is leading a research effort he hopes will retool the discharge process in U.S. hospitals. “We throw papers and throw words at patients. It is crazy to think they would understand,” he says. This is especially true of older patients and those who are depressed.

The new approaches rely on video and audio recordings that can be replayed along with provider follow-up.

The FEHBlog trusts that his readers enjoyed the Thanksgiving holiday. The House of Representatives and the Senate resume attending to the people’s business tomorrow with twelve days left before the continuing resolution funding the federal government expires on December 11.  The Hill reports on the key measures pending before Congress this month.

The Federal Benefits Open Season has two weeks left before its conclusion on December 14. Tammy Flanagan provides advice on items for federal and postal employees to consider before then.

Health Data Management makes five cybersecurity predictions for 2016 (none encouraging) while OPM introduces the public to Clifton Triplett, the new senior cybersecurity advisor to the agency’s director.

The Wall Street Journal reports on how the collapse of New York State’s health care co-op, Health Republic Insurance, is costing the State’s medical practices millions of dollars in unpaid claims. The irony is that there was no reason for Congress to create these new co-ops in the ACA because there are plenty of non-profit insurers. In any event, the ACA is aimed at limiting the net income of for profit and non-profit insurers.

Federal News Radio reports that OPM is experiencing a busy Federal Benefits Open Season due to the availability of the new self plus one enrollment type. “Typically within the first two weeks of Open Season, the volume of changes processed is between 90,000 to 130,000. This year, OPM officials said, from the start of Open Season on Nov. 9 through Nov. 20, more than 270,000 enrollment transactions have been processed.” OPM has estimated that 1 million enrollees are in a position to select the self plus one enrollment type (roughly 50% of the current self plus family enrollees).  The article also explains how enrollees can switch to self plus one if they miss this Open Season opportunity which ends on December 14.

Here’s OPM’s advice on how to make enrollment changes this Open Season:

Annuitants with access to a computer should visit https://retireefehb.opm.gov/Annuitant/ Due to the high number of calls to Open Season Express, OPM strongly encourages use of the on-line enrollment system. Annuitants who do not have access to a computer can call Open Season Express at 1-800-332-9798. The Open Season Express phone line is a dedicated line for FEHB Open Season actions only. 

Employees should visit OPM’s Open Season website www.opm.gov/healthcare-insurance/open-season/ for information. Open Season Express is not for employees. They will be directed to contact their agency for assistance.

In an interesting development, a bipartisan group of Senators and Representatives has asked the White House for a meeting on creating a path to repealing the excise tax on high cost employer sponsored coverage.

The Centers for Medicare and Medicaid Services have reported on the state of ICD-10 coding implementation in the Medicare and Medicaid programs according to this EHR Intelligence article.

Last week, the Department of Health and Human Services held a pharmeutical forum. MedScape reports on the conference here. The article opens as follows:

The increasing number of patients using specialty drugs has helped to drive a 12% increase in the nation’s overall pharmaceutical spending so far in 2015, according to an analysis presented at a US Department of Health and Human Services (HHS) conference Friday [November 20].

The Wall Street Journal reports today on a study finding that surprising price increases are also affecting dermatologist drugs — whether or not they are specialty drugs.

Retail prices of 19 brand-name prescription drugs for dermatologic conditions ranging from acne to cancer increased fivefold on average between 2009 and 2015, according to a study that adds new fuel to the burgeoning debate over the cost of medicines.

The Medscape article concludes with the following official observations from the HHS Forum:

Both [HHS Secretary Sylvia] Burwell and [CMS Acting Administrator Andy] Slavitt said that the government was trying to balance the need for new therapies — and companies’ ability to innovate and compete — with patients’ access to affordable products. Slavitt said that the feds wanted more transparency on how prices were set, and would seek more effectiveness data, also. “We must increase the transparency of the information available about drug pricing and value,” he said. And the government is also looking at creating incentives for drug makers to prove value — such as rewards for keeping patients out of hospitals, he said. “How do we think in terms of episodes of effective treatment, rather than just the cost of a pill?” said Slavitt.

Fair question.

Late Friday afternoon, shortly after the FEHBlog hit post on Friday’s message, HHS issued its proposed ACA benefit and payment parameter notice for 2017 which clocks in at 381 pages.  This rule principally provides guidance to qualified health plans in the exchanges but some of the guidance  extends to plans outside the exchanges including FEHB plans.  Here are links to the HHS fact sheet ,  Professor Tim Jost’s initial column on the annual rulemaking, and even a Washington Post article.

With respect to provisions that do apply to the FEHBP, the notice proposes  (p. 215)that the “2017 maximum annual limitation on cost sharing would be $7,150 for self-only coverage and $14,300 for other than self-only coverage.”  For 2016, “The maximum out-of-pocket limit for self-only coverage is $6,850 (up from $6,600 in 2015). For coverage other than self-only (such as family coverage), the maximum out-of-pocket limit is $13,700 (up from $13,200 in 2015).”  The maximum applies to deductibles, copayments and coinsurance but not premiums or out of network provider charges.

The notice (p. 275-76) also proposes to end the transitional reinsurance program after 2016 as it must.  The transitional reinsurance program requires most FEHB plans to contribute to a fund to help finance the QHPs in the exchanges.

This Week in Congress reviews the current week’s activities on Capitol Hill here. The House and Senate are leaving town for Thanksgiving and will return on November 30. At that point, there will be eleven calendar days for Congress to extend or finalize the continuing resolution that currently is funding the federal government.

Federal News Radio explains  with the help of Walt Francis why Open Season doesn’t have to be overwhelming.  Open Season continues until Monday December 14. Here is a link to the online chat that Federal News Radio held with Mr. Francis earlier this week.

Drug Channels reviews the steps that prescription benefit manager is taking to weed out of their retail networks pharmacies that have unholy links with drug manufacturers or act as mail order pharmacies, similar to Philidor.

The Wall Street Journal reports that the Centers for Medicare and Medicaid Services is considering imposing a penalty on doctors who order PSA tests which screen men for prostate cancer. “Since 2012, the U.S. Preventive Services Task Force has recommended against routine screening for prostate cancer for men of any age on the grounds that the benefits don’t outweigh the harms.”  This is another government initiative for value based medicine. According to the article many doctors aren’t amused by the initiative.

“PSA screening is a very controversial topic. The debate is ongoing and people feel very strongly about it, one way or another,” said David Penson, chair of public policy and practice support for the American Urological Association, which urged CMS to reject the proposal. “To make it a quality measure would say, ‘You’re a poor quality doctor if your patients get this test.’ ”

Govexec.com suggests the best ways that federal and postal employees and retirees can obtain assistance with their Federal Benefits Open Season decisionmaking.

Avalere Health has concluded not surprisingly that health insurance premium changes reflects consumer spending on healthcare.

The prescription benefit manager (“PBM”) trade association informs us on the battles between PBMs and independent pharmacies that are being waged on Capitol Hill.

According to Medpage Today, the Centers for Medicare and Medicaid Services is pushing ahead with its initiative to create a new quality based payment model for joint replacement surgeries performed on Medicare beneficiaries.  “Known as the Comprehensive Care for Joint Replacement (CCJR) rule, the new regulation requires bundled payments for joint replacements to the lower extremities over a 90-day “episode of care” in 67 metropolitan areas.” The mandatory pilot takes effect April 1, 2016.

Finally Modern Healthcare reports that “Hospital and physician groups are cautioning the CMS that it needs better [quality] measures before it ties physician pay to quality and outcomes.” The FEHBlog expects that payers appreciate the providers’ concern.

OPM today posted its FY 2015 financial statements which discuss the FEHBP at several points — in particular Strategic Goal 9 beginning on page 23. On page 123, you will find a general OPM response to the Inspector General’s management challenges and recommendations which the FEHBlog discussed last week.

Professor Tim Jost in his Health Affairs explains that

The final rules make no major changes in the interim rules. Indeed, they make virtually no changes in the interim rules as interpreted by current guidance.
What the final rules do in many instances, however, is to incorporate existing [FAQ] guidance into final rule form. As guidance is not as legally authoritative as are regulations, this clarifies the legal status of existing interpretations of the rules. The finalization of these rules also makes it more difficult for a future administration to change them as the Obama administration nears its final year.
The final rule will go into effect on January 1, 2017, at which time the interim rules will no longer remain in effect.

The FEHBlog disagrees with Mr. Jost that the finalization of the rules makes it more difficult for a future administration to change them as interim rules are final rule. It is stunning to the FEHBlog that the ACA regulators did not open a new comment period given the lapse of time since the first round of comments.  But that’s the ACA for you.

We are entering the second week of the Federal Benefits Open Season. A reader submitted a FEHBlog comment  late last week asking about a particular plan’s prescription drug coverage. Because the FEHBlog represents FEHB plans, he will not post comments about plans, either positive or negative.  However, if readers want to email the FEHBlog with questions, he will try to help out.

Also this week, the federal agencies are issuing their financial statements for the fiscal year  that ended September 30, 2015.  Here is a Federal News Radio article on the Postal Service’s financial report which indicates that the Postal Service is banking, in part, on Sen. Carper’s postal service health program measure.  That measure would fully integrate Postal Service annuitant coverage with Medicare while preserving the existing risk pool structure — employees and annuitants in the same risk pool per plan option.

Finally, the FEHBlog’s attention was drawn to the Boston Globe article on health insurer efforts to tackle our country’s opioid abuse crisis with supported for those afflicted by it.

The growing costs — in the billions of dollars nationally — have spurred insurers to tackle the opioid problem through a variety of new measures, including imposing restrictions on prescriptions for painkillers like Vicodin and OxyContin, because addiction often starts with such drugs, lifting restrictions for addiction treatment, and deploying case managers and coaches to guide patients through treatment.
Blue Cross Blue Shield of Massachusetts, which first put limits on opioid prescriptions three years ago, is now contacting its members who are in detox programs to help coordinate their care and prevent relapses. Boston Medical Center HealthNet Plan, a subsidiary of Boston Medical Center, has assigned staff to call and visit members with addiction to help them find and stick with treatments.
Neighborhood Health Plan, the insurance arm of Partners HealthCare, where nearly 9 percent of members were diagnosed with substance abuse in the last year, recently partnered with Massachusetts General Hospital to hire a recovery coach to help members stay sober.

Well done.